What are the treatment options for hiccups?

Treatment Options for Hiccups

For hiccups, treatment should follow a stepwise approach starting with physical maneuvers for acute cases, progressing to chlorpromazine (25-50 mg three times daily) as first-line medication for persistent cases, and considering alternative medications like baclofen, gabapentin, or metoclopramide for refractory cases. 1

Classification of Hiccups

Hiccups are classified based on duration:

• Acute: Less than 48 hours
• Persistent: More than 48 hours but less than 2 months
• Intractable: More than 2 months 1

Treatment Algorithm

Step 1: Physical Maneuvers (First-Line for Acute Hiccups)

For hiccups lasting less than 48 hours, try these techniques:

• Breath-holding
• Rapid water drinking
• Swallowing granulated sugar
• Pulling on the tongue
• Stimulating the uvula/pharynx
• Larson maneuver (suprasternal pressure) 1

These physical techniques work by disrupting the hiccup reflex arc and are recommended by multiple medical organizations as first-line treatment for acute hiccups.

Step 2: Pharmacological Treatment (For Persistent Hiccups)

If physical maneuvers fail or hiccups persist beyond 48 hours:

First-line medication:

• Chlorpromazine: 25 mg three times daily
• Can be increased to 50 mg three times daily if ineffective after 2-3 days 1, 2

The FDA-approved dosage for intractable hiccups is 25-50 mg three times daily or four times daily 2.

Alternative medications (if chlorpromazine is contraindicated or ineffective):

• Baclofen: Particularly for central causes of hiccups
• Gabapentin: Effective for neuropathic-related hiccups
• Metoclopramide: Useful for peripheral causes, especially GI-related hiccups 1, 3

Step 3: Advanced Interventions (For Intractable Hiccups)

For hiccups persisting beyond 2 months:

• IV chlorpromazine under careful monitoring
• Nerve blocks
• Nerve stimulation
• Acupuncture 1

Special Considerations

Underlying Causes

Always identify and treat underlying causes of persistent hiccups, which may include:

• Gastroesophageal reflux disease
• Myocardial ischemia
• Central nervous system disorders
• Medication side effects 1, 3

Monitoring and Precautions

When using chlorpromazine:

• Monitor for hypotension, sedation, and extrapyramidal symptoms
• Use lower doses in elderly, debilitated, or emaciated patients
• Be aware of QT prolongation risk, especially when combined with other QT-prolonging medications 1, 2

Common Pitfalls to Avoid

1. Failure to identify underlying causes: Treating symptoms without addressing the root cause can lead to prolonged hiccups 1
2. Overlooking drug interactions: Particularly with QT-prolonging medications when using chlorpromazine 1
3. Using high doses in vulnerable populations: Elderly patients are more susceptible to adverse effects and require lower dosages 1, 2
4. Premature escalation to pharmacotherapy: For acute hiccups, physical maneuvers should be tried first before moving to medications 1

While numerous treatments for hiccups have been reported over centuries, the evidence for many interventions remains limited. The stepped approach outlined above represents the most current guideline-based recommendations, with chlorpromazine having the strongest evidence and FDA approval specifically for intractable hiccups 1, 2, 3.